Medicare's future

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Regardless of whether Democrats take control of the House or Senate or both, they plan to undo the Medicare drug program. Indeed, recently House Minority Leader Nancy Pelosi promised that if Democrats took control of Congress, her party would eliminate the choice of private-sector plans in favor of a single government purchaser for seniors' medications. If they try, they'll be in for a shock. Medicare has again become the third rail of politics.

Seniors like Part D. It has given drug coverage to 20 million people who didn't have it before. It has lowered costs for most seniors. It has come in substantially under budget — the 10-year estimates for the program's cost have already dropped by a fifth. And it has given them access to nearly 90 percent of all available drugs without any bureaucratic interference.

This coming year, drug plans have announced they will offer more choices and more coverage for lower prices and lower premiums. Mrs. Pelosi wants to turn this popular program, where the consumer continues to make decisions, into a program where one buyer — the federal government — determines everything.

Critics think they can cut costs more dramatically than consumer competition is already doing, and they are right. But they can do so only by drastically limiting the choice of medicines that doctors and seniors now have. That's how the Department of Veterans' Affairs (VA) ratchets down prices. Like Canada, England and other single-payer plans, the VA sets a price and gives one drug and one company all the business at that price. As a result, the VA drug plan offers 30 percent fewer drugs than the average Medicare plan.

Only 38 percent of the drugs approved in the 1990s, and 19 percent of the drugs approved by the Food and Drug Administration since 2000, are on the VA National Formulary. Only 17 percent of the 77 priority-review drugs (22 percent) approved since 1997 are on the 2005 National Formulary.

For instance, before the VA will dispense Gleevec to veterans suffering with stomach cancer, they first must try an older drug known for its harsh side effects. The VA is delaying access to the cancer drug Avastin for a year, regardless of whether affected veterans have that year to wait. Worse, many Medicare drug plans actually cost less than the VA, which requires veterans to fork over nearly $1,000 a year for fewer choices.

And since Democrats like Sen. Hillary Clinton and Rep. Henry Waxman are in love with cost-effectiveness studies that justify limiting the use of new medicines, they will be forced to defend delaying and denying the use of drugs for such diseases as Alzheimer's, just as such research has been used to ration access to similar medications in the VA, Canada and the U.K.

But simply beating up Democrats for robbing seniors of life-saving medicines isn't enough. Republicans should distinguish themselves from the Democratic "pay more for less choice" proposal by encouraging seniors to enroll in health plans that offer both prescription drugs and programs that actually control and prevent disease.

Right now Medicare gives health plans a subsidy to enroll seniors. That's not good enough. Let the market drive down the price of plans and premiums, just like they have reduced the cost of the drug benefit. Then health plans should be rewarded for improving the health of the sickest patients and keeping people healthy, and seniors who stay well should get some rebate. Since 70 percent of Medicare spending goes to paying for people with chronic disease, why not invest in services and technologies that prevent illness in the first place?

The heart and soul of this transformation to predictive and preventative care is the freedom to tailor the drugs and type of care required to genetic variation and individual risk factors. And it is also the source of growing support for the Medicare program. If Democrats want to simply attack drug prices, it will force them into a one-size-fits-all strategy that only worsens the burgeoning cost of chronic illness. It leaves Republicans with a golden opportunity to depict them as opposed to medical progress, individual choice and fiscal sanity.

Regardless of who controls Congress, Republicans should seize that chance to lead.

Robert Goldberg is vice president for strategic initiatives for the Center for Medicine in the Public Interest.